This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Wednesday, 14 April 2010

The Onus is on the Nursing Staff

45 minutes to dismantle, clean and rebuild a bed.

This is the trust's latest trick in fighting infection control.

They continue to ignore the issues of safe staffing while scoffing at any suggestions made by the professional nursing staff regarding this matter. They are unable to address the issue of high bed occupancy as a result of being forced to meet targets. In a nutshell, this means that the ward is always to full to clean properly. We continue to get slammed with admissions we cannot handle at mealtimes, during rounds, change of shift, and when we are struggling to care for the patients we already have. We don't have enough domestics. We have no right to have an uninterrupted block of time at any point in our shifts to do our jobs. We are doing so many things at once that nothing, NOTHING gets done well.

None of this gets addressed. Ever.

But the trust behaves as if it is quaking in their boots at the thought of getting busted over poor hygiene, super bugs and poor care. They cannot deal with the real issues that lead to these problems so they are covering their assess and putting the onus on the Nursing Staff.

I attended a study update the other day to learn about the trusts requirements for the cleaning of all 30 beds on the ward. The process that we were instructed upon is to be implemented daily and between every discharge and admission. They want each bed completely dismanted and every part cleaned in a certain way, every single day and between each patient. It is heavy work that requires at least 2 members of staff. It takes at least 45 minutes to do one bed.

There are 30 beds. We have between 5 and 15 discharges and admissions per day. There are 2 nurses and 2 assistants for a 12 hour shift during the day who cannot even attend to all the Nursing care that needs to be accomplished.

Do the Math.

We cannot even get around to everyone fast enough to prevent pressure sores, dehydration, notice changes in condition quickly enough or medicate properly. Here's a newsflash for the doctors: you know those IV antibiotics that you prescribe to be given 4 times a day? They are getting given two times a day max because the nurse has so damn many of them to mix and give that it takes hours. Yeah, doses get missed regulary.

Now you need to take into account that in addition to this we must clean and dismantle 30 beds that take 45 minutes each to clean every day. And in addition to that we have to dismantle and clean them between each patient.

They won't bring more staff on board. They don't want the domestics doing the beds and there are not enough of them anyway.

During the course of the study update we did explain that we will be unable to follow this bed policy due to a lack of time and staff.

This statement was met with ridicule of the Nursing Staff in the form of eye rolling and the inferred notion that Nurses are too thick and lazy to do their job properly.

And I quote: " The trust is implementing this policy to prevent the spread of infection. There will be spot checks to ensure that these actions are being carried out. If they are not, the blame is on the professional Nursing staff."

Did I tell you that they want us to spend 11 minutes exactly in a cramped room cleaning and dismantling commodes and documenting it between each patient use. Four commodes are being used over 15 times an hour on some days. They are swabbing them to ensure that this is done. The swabs are never clear. And infection control is up our asses over it. They have devised even more cleaning checklists and paperwork. Same with pressure sore audits etc.

And they want to know why we have so many pressure ulcers, and drug errors as well. And they have demanded that the RN on duty drop what she is doing as soon as the consultants arrive (we don't know when they are coming and cannot plan for it) and attend every ward round, following the medical teams around the ward for hours while they see their patients.

And if my patient suffers harm because I am off on a ward round or dismantling a bed I must take full responsibility. It's tough shit really.

Fuck them. I am going to Nurse my patients starting with the high priority actions and working my way down. I will turn the patient and if that doesn't leave time to document that I have turned them it is too bad. The trust wants documentation that it is done more than they want it to actually get done.

28 comments:

murse
said...

So, what do we do? Maybe you could get a regular spot in the Guardian now that nhsblogdino has apparently expired? Doesn't change the fact that nobody (including our pathetic simpering 'unions' gives a shite about nurses unless they are one (or married to one and tired of the moaning). When we do tell people how it really is they don't fucking believe it anyway. Still planning on voting with your feet?

Your Trust sounds an awful place to work. I know that the NHS has a bad reputation regarding whistleblowers but it may well be the only thing left to do. As a group, nurses are piss poor at standing up for themselves in this country- problem ingrained within the public sector. Its about time that we actually did something constructive and went on strike. I'm not advocating that we walk of the wards but leaving on time at the end of a shift, not doing overtime to save money on agency, working to your job description...would do for starters.

I think it's about high time that some of our so called 'leaders' were shown the truth of their incompetence. If only one ore two could get their faces out of the trough, and actually visit some of the places and things that that they have ruined. Without SMT hanging around. I suggest enlisting Guy Fawkes (or similar) to create some er, customers...

I think it's about high time that some of our so called 'leaders' were shown the truth of their incompetence. If only one ore two could get their faces out of the trough, and actually visit some of the places and things that that they have ruined. Without SMT hanging around. I suggest enlisting Guy Fawkes (or similar) to create some er, customers...

Dear Annethose managers are nicompoops and don't understand their job is to FACILITATE clinical staff. Be real sweet and ask them for a demonstration in the ward ? just to be real sure as to how it's done and whilst someone is dismantling ask them to take over some nursing eg iv medication or get a bedpan for a patient. Bet u they won't bother. Is this coming from infection control people ? I get so mad on your behalf.Anna

Just wondered where you are from though? I know you work in the UK, but a lot of what you write sounds like it was written by an American because of the phrases and words (e.g. "You do the Math", "up our asses" etc).

Our trust had a similar little directive to the on-call doctors recently - apparently there has been a problem with on-call jobs and patient reviews not being done in a timely enough fashion, on a completely unrelated note doctors are not documenting in the notes with enough detail when they see patients on-call.

Fortunately the solution is quite simple, the doctors will spend more time writing in the notes and also see more patients - problem solved.

When it was suggested that perhaps these were conflicting priorities and that maybe the problems highlighted a need for more on-call staff it was made quite clear that these recommendations will be implemented, there will be no more staff, and it will be a 'professional misconduct' issue if doctors are not able to comply.

A similar issue was seen with medical staffing where they did not attempt at all to find locum cover for known abscences, then at the last minute they ring up the rest of the doctors to inform them that they are obliged to cover the shifts* between themselves and failure to do so would again be 'professional misconduct'.

What is interesting is that there is apparently no concept of professional misconduct for these admin and management arseholes who get to tell everyone else what to do while going home early and apparently taking no responsibility for the mess they leave preside over.

* Of course the ensuing failure to meet European Working Time Directive limits is, funnily enough, the responsibility of the individual doctors and can be subject to 'disciplinary action' for working too many hours!

I am new to blogland and am still not quite sure of what I am doing. I have mentioned this post in my third blog. If I have infringed blog etiquette - I apologise and would ask that you advise me of same.

Watched a programme the other day on German TV about the new super-hospital in Nuremburg which opened a couple of years ago. It has a "dishwasher" for beds - between patients every bed is pushed into a room which is like the dishwasher you see in pubs for the glasses. It's washed with high-pressure jets, subjected to a disinfection cycle and dried. All automatically, just pushed in by the technician running it, doors closed, push the button and hey presto! As far as I remember, the patient is picked up from wherever they are admitted in the bed so 1 patient equals 1 bed reducing cross-contamination - they do have the advantage of a new purpose-built building which allows enough space for a bed rather than having to put your patient onto a trolley just so they fit in the space and of course there is also a reduction in the risks to backs of moving patients back and forth.

Great Blog. Glad to see nurses talking about how broken the system (s) is (are), not just where I work but everywhere. Not only that, but from what you describe at your work, I will be a bit more cognizant of how good my job is. Not to ignore that we do also have problems galore, but nothing on the level of what you endure.

Our lot recently came up with the genius idea of attaching checklists in little plastic pockets to all the dripstands so that instead of doing anything remotely useful we nurses could fill in these checklists every time we cleaned a dripstand.

They were quite proud of their little notion until I said "But who is going to clean the plastic pockets attached to the dripstands? Don't we need a second checklist for that?"

I am so glad to have found this blog. WTF is going on? How can these baw bags get away with this? The NHS was never perfect but it did at one time strive to deliver quality care. I left 2 yrs ago mid shift after working for 16yrs and it just seems to be getting more cynical. It seems to be the people that give a shit that are being isolated and burned out. They keep on putting posters up about violence against nurses not being tolerated. But keep on putting violent patients alongside very ill patients and we have to jump in like fukkin super heroes to stop some poor bastard getting a hospital acquired facial injury to accompany their o/a presentation.The worst part of it is that the person who needs restrained is wired to the fukkin moon and is not responsible for what they are doing and have usually been banged up with benzos for so long that when paradoxical aggression kicks in the whole thing is fukkin chaos. I am going to leave it there but it gets me so fukkin angry they can stick their posters and benzos up there arse. We need proper units with appropriate staffing to meet the very complex needs of potentially aggressive patients.

Your place sounds like mine.... we know have weekly cleaning lists, including toilets, changing rooms, visitors rooms, overnight accomodation and staff rooms added to our list of things we are supposed to clean,thats on top of the beds, multiple equipment and stock trolleys and rooms, oh and lets not forget the hour long computer assessment on clunky old NHS software that is worse than useless.all the while working a 13 and a half hour day.. and looking after our Intensive care patient.If I see another 'tick list' from management for some target they want us to reach so they get a fancy logo to stick on their letterhead I think I,m going to scream.

With reference to Ulrike's comments it isn't the good HCA's that are a problem it's the bad ones. I could kiss the good ones, I really could. Also, am a bit surprised you are not allowed to write in notes. Hell, even the lowest level support staff on our ward were allowed to write in the patient's care plans. One snitch used to monitor what the nurses did and write down comments on whether they had done things well or not in her opinion. She was 'bestest fwiends' with the ward sister, they were like siamese twins - if she had got any closer at handover she would have been perched on the sister's lap! You can't fight this set-up. Why was an auxiliary (with only a couple of years experience) allowed to behave this way? One day when I was with a consultant doing the ward round I told her to clean up a patient who had just messed himself and she actually refused and started arguing with me (and it wasn't the first time this had happened. Management just let her get away with this sort of thing. How I longed to kick her up her fat lazy little backside. How can nurses do a proper job with support staff who indulge in challenging behaviour like this? A hospital ward is no place for a worker who acts like a primary school child, it just isn't fair to the patients, it really isn't.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.